JIRA Link: 

Review Link: JIRA IHTSDO-175 (artf6226) Implantation Procedures Documentation Review

Word version of current page: IHTSDO-175 Combined Inception-Elaboration_Construction document v0.4.docxI

Amendment History

Review Timetable

Introduction

The purpose of this project is to address the remaining unresolved issues from the 3 issues originally identified in the original tracker IHTSDO – 175.
Two of the issues and the affected concepts have been actioned and are now placed in the hierarchy as recommended:

1. Grafting - action should be a subtype of Implantation - action.
2. Grafting - action should possibly be a made a subtype of Surgical insertion - action (qualifier value).

This project will review the Implantation procedure area of the hierarchy.

Scope of the project

As proposed in the content tracker IHTSDO-175 Implantation, grafting and surgical insertion, the definition and modeling of Implantation (procedure) hierarchy (>2800 descendants) requires review.
This project will focus on the review of the Implantation procedure area of the hierarchy and analysis of the placement of subtypes. Additionally, synonyms will be assessed to confirm the validity of these on a number of related concepts in this area.
Included in the scope is the testing of the proposed solution to understand the impact of making changes i.e. classification results after remodelling demonstrating the new placement in the hierarchy and a plan for construction of the revised model.

Examples of inappropriate relationships:

Content Issue Summary

Summary of issue

There are three main issues that this project is attempting to resolve:

1. In SCT: Insertion and implantation are synonymous.
2. 71861002 |Implantation (procedure) is defined as Introduction of a non-biologic device and modelled with Method = Insertion - action.
3. Ambiguity in FSNs e.g. 119627001 |Arm implantation (procedure)|

As a result of #1 it is not possible to distinguish between types of procedures, i.e., are they insertions, implantations or surgical insertions? While the definitions as commonly understood are similar, the clinical application of these to describe procedures renders them separate; Insertion and implantation are not synonymous.

Current view of the concept Implantation

Note the erroneous synonyms and misleading definition on this concept as follows:

• Insertion
• Insertion procedure
• Implantation of non-biologic device

As a result of #2 above, improper inferences occur. The definition is problematic as not all subtypes of Implantation (procedure) I employ non-bological devices, eg. 119561005 |Grafting procedure (procedure)| has 172 subtypes not all employing non-biological devices.

As well, non-synonymous synonyms lead to incorrect inferences. Implantation procedures are not subsumed under 387713003 |Surgical procedure (procedure)| as Implantation procedures use Method = 257867005 |Insertion - action (qualifier value)| which is not a subtype of 425362007 |Surgical insertion - action (qualifier value)|.

The result of issue #3 is that there are concepts, which are ambiguous, which should be inactivated. Please see full list in the appendix.

These 3 issues are further compounded by the fact that 257867005 |Insertion - action (qualifier value)| has synonyms of implantation and placement of implant. There are concepts with Insertion or implantation in the FSN, all are modelled with Method = Insertion – action.

Current view of the concept Insertion

Note the erroneous synonyms:

• Implantation
• Placement of implant

Subtypes of Implantation procedures infer incorrectly eg. 41976001 |Cardiac catheterization (procedure)| is a subtype of 119764000 |Heart implantation (procedure)| as both concepts are modelled with Method = 257867005 |Insertion - action (qualifier value)|. On the face of it, supported by the synonyms of placement of implant and implantation, this fits. However, a diagnostic cardiac catheterization does not involve implantation of a catheter; it does involve insertion of a catheter. It may however become an angioplasty/stent implantation procedure. Two separate procedures possibly combined in one episode of care.

Definitions

The distinction between the concepts Introduction, insertion, and implantation are nuanced.
Although the definitions are not the same, clinically when we say, "insert" we are referring to the actions in the definitions of "introduce" i.e. to put inside or into, insert or inject, an action of putting in or inserting.

Hence we have an instrument called an "introducer" NOT an "inserter". 

Related known issues

These trackers were reviewed but did not provide any pertinent information although somewhat related.

Analysis of issue

The approach was to examine the Implanatation procedure hierarchy and create a solution to align the content and provide consistent meaning.

• Review the definitions of Insertion, implantation, transplantation, introduction and surgical insertion.
• Review Implantation procedure modelling, subtypes and the qualifier values as modelled for Method attribute.
• Review qualifier values in use in Implantation procedures.

Using the SCA tool, queries were run to reveal usage of said concepts and uncover issues.

1. Incorrect inferences:
71861002 |Implantation (procedure)| not subsumed under 387713003 |Surgical procedure (procedure)| since Implantation procedures use value for Method = 257867005 |Insertion - action (qualifier value)| which is not a subtype of 425362007 |Surgical insertion - action (qualifier value)|

Additionally, the concept has a definition in SNOMED CT of Introduction of a non-biologic device. However this is incorrect and causes problems e.g. One of the subtypes 119561005 |Grafting procedure (procedure)| which has 172 subtypes not all employing non-biological devices, including:

 Advancement of pedicle graft (procedure)
      Allogeneic peripheral blood stem cell transplant (procedure)
Allograft of amniotic membrane (procedure)
 Arthrodesis of metacarpophalangeal joint with autograft (procedure)
      Arthrodesis of wrist joint with sliding graft (procedure)
      Arthroplasty of temporomandibular joint with allograft (procedure)
      Arthroplasty of temporomandibular joint with autograft (procedure)
      Artificial graft (procedure)
      Attachment of pedicle flap graft (procedure)
       Autogenous graft of rib cartilage to chin (procedure)

2. Improper placement in hierarchy:

• 257867005 |Insertion - action (qualifier value)| Procedures being classified as Placement of implants due to synonym = Placement of implant - there are 1608 procedure concepts which infer this value for attribute Method. Many are not Placement of implants. Examples: 265641004 |Packing to control postnatal vaginal bleeding (procedure)|710132004 |Insertion of catheter into artery using fluoroscopic guidance (procedure)| 426074005 |Insertion of therapeutic substance into brain tissue (procedure)|

3. Ambiguity

• 71861002 |Implantation (procedure)| has 175 inferred subtypes some of which are "insertion procedures" but classify under Implantation and some where the FSN has the word Implantation but are modeled with Method = Insertion – action. Others are ambiguous. Examples:44868003 |Acupuncture (procedure)|29747000 |Evisceration of ocular contents with implant into scleral shell (procedure)|119627001 |Arm implantation (procedure)|does this mean an arm was implanted or that something was implanted into the arm?

Example: 119707005 |Nose implantation (procedure)| FSN states implantation; modelling has Method = insertion - action

Current model of concept

Related issues

Solution

Reach agreement on definitions for implantation, introduction and insertion.
Remove inappropriate synonyms and definitions.
Clean up ambiguous FSNs on implantation procedures.
Provide separate concepts to allow modelling of Insertion and Implantation procedures with appropriate values for Method attribute i.e. insertion and implantation.
Re-organise the qualifier values for Implantation and insertion as subtypes of surgical action to allow appropriate inferences i.e. surgical procedures align under surgical procedure hierarchy.
Harmonise FSNs on implantation and insertion procedures with the modelling.
E.g. Existing Implantation procedure has 70 inferred subtypes that have to be reviewed and revised to harmonise qualifier values with FSN.

Consideration given to

129325002 |Introduction - action (qualifier value)| - grouper
Inactivate as ambiguous or duplicate to Insertion
8 stated subtypes:

•       Administration - action (qualifier value)
•       Application - action (qualifier value)
•       Insertion - action (qualifier value)
•       Intravesical drug therapy (qualifier value)
•       Replacement - action (qualifier value)
•       Surgical introduction - action (qualifier value)
•       Tamponade - action (qualifier value)
•       Transplantation - action (qualifier value)

424832003 |Surgical introduction - action (qualifier value)|
Inactivate as duplicate or ambiguous equivalent to 425362007 |Surgical insertion - action (qualifier value)|
Only 4 concepts are subtypes:
265597008 |Implantation of bulbar urethral prosthesis for incontinence (procedure)|
69264004 |Kaufman operation for urinary stress incontinence (procedure)|
180004007 |Implantation of bioelectrical prosthesis for limb (procedure)|
425362007 |Surgical insertion - action (qualifier value)|

Construction

Reactivate 129336009 |Implantation - action (qualifier value)|

Reactivate as subtype of 424832003 |Surgical introduction - action (qualifier value)| Upon further review this was reactivated as a subtype of 129325002 |Introduction - action (qualifier value)| as there are implantation procedures that are not surgical. 

This concept is a synonym on the concept Insertion:

• Make 129337000 |Reimplantation - action (qualifier value)| a subtype
• Make 129407005 |Grafting - action (qualifier value)| a subtype
• Make 129406001 |Transplantation - action (qualifier value)| a subtype

Snapshot January 2018 release shows this hierarchical arrangement:

After testing the solution, the hierarchy looks like this:

257867005 |Insertion - action (qualifier value)|

• Remove synonyms pertaining to implantation or placement of implant
• Retain as subtype of introduction for use with non-biological devices

71861002 |Implantation (procedure)| - grouper

• Remodel with Method = 129336009 |Implantation - action (qualifier value)|
  • Remove definition Introduction of a non biologic device
  • Remove synonyms which state "insertions"
  • Remove Method – insertion – action
  • Remodel subtypes to harmonise

129406001 |Transplantation - action (qualifier value)|

• Remove parent Introduction and make it a subtype of 129336009 |Implantation - action (qualifier value)|
• Remodel 425362007 |Surgical insertion - action (qualifier value)| to parent 424832003 |Surgical introduction - action (qualifier value)|
• Remodel 424832003 |Surgical introduction - action (qualifier value)| to parent 129284003 |Surgical action (qualifier value)|

Create new Insertion procedure

Create new concept 767537003 |Insertion procedure (procedure)| and model with Method = 257867005 |Insertion - action (qualifier value)| for those procedures which are non-surgical.

Remodel 228 Surgical procedure concepts currently using Method 257867005 |Insertion - action (qualifier value)|. Instead remodel with 425362007 |Surgical insertion - action (qualifier value)|

Remodel procedure subtypes to harmonise FSN with model i.e. Insertion with Insertion – action (qualifier value), Implantation with qualifier value Implantation – action.

Summary of modelling changes that have been tested

Of note after testing:

Changing the Method attribute on 71861002 |Implantation (procedure)| from Insertion to Implantation as shown here

Resulted in the classifier assigning 671 Inferred not previously stated relationships e.g.

These would have to be reviewed to ensure accuracy but it looks like this would help to clean up the procedures where implantation is the action but the concepts are not subtypes of Implantation procedure.

Recommendation

As a first step the Implantation procedures that have ambiguous FSNS could be reviewed and either rewritten to make the meaning clear or be inactivated as ambiguous. It has been suggested that many are groupers that do not have to be recreated.

Ambiguous as do not state any Substance or Device or whether the action is implanting the body structure into something, or implanting something into the body structure.

Here is the list of current concepts which require review and possible inactivation:

•  ≡   Abdomen implantation (procedure)
•  ≡   Abdominal artery implantation (procedure)
•  ≡   Accessory sinus implantation (procedure)
•  ≡   Adenoid implantation (procedure)
•  ≡   Ankle implantation (procedure)
•  ≡   Anterior segment of eye implantation (procedure)
•  ≡   Anus implantation (procedure)
•  ≡   Aorta implantation (procedure)
•  ≡   Arm implantation (procedure)
•  ≡   Biliary tract implantation (procedure)
•  ≡   Bladder implantation (procedure)
•  ≡   Bone marrow implantation (procedure)
•  ≡   Brain implantation (procedure)
•  ≡   Breast implantation (procedure)
•  ≡   Bronchus implantation (procedure)
•  ≡   Cannulation (procedure)
•  ≡   Cervix implantation (procedure)
•  ≡   Coronary artery implantation (procedure)
•  ≡   Ear implantation (procedure)
•  ≡   Endocrine gland implantation (procedure)
•  ≡   Epididymis implantation (procedure)
•  ≡   Esophagus implantation (procedure)
•  ≡   Eyelid implantation (procedure)
•  ≡   Facial bone implantation (procedure)
•  ≡   Fallopian tube implantation (procedure)
•  ≡   Foot implantation (procedure)
•  ≡   Gallbladder implantation (procedure)
•       Gastrointestinal tract implantation (procedure)
•  ≡   Hand implantation (procedure)
•  ≡   Head artery implantation (procedure)
•  ≡   Heart implantation (procedure)
•  ≡   Implant of larynx (procedure)
•  ≡   Implantation of biliary fistula (procedure)
•  ≡   Implantation of cornea (procedure)
•  ≡   Implantation of diaphragm (procedure)
•  ≡   Implantation of heart valve (procedure)
•  ≡   Implantation of nerve (procedure)
•  ≡   Implantation of pharynx (procedure)
•       Implantation of premaxilla (procedure)
•  ≡   Implantation of prosthetic device (procedure)
•  ≡   Implantation of prosthetic limb device (procedure)
•       Implantation of retinal attachment (procedure)
•  ≡   Implantation of skin of extremities (procedure)
•  ≡   Implantation of spine (procedure)
•  ≡   Implantation of tongue (procedure)
•  ≡   Implantation of vitreous (procedure)
•  Integumentary system implantation (procedure)
•  ≡   Kidney implantation (procedure)
•  ≡   Large intestine implantation (procedure)
•  ≡   Lip implantation (procedure)
•  ≡   Liver implantation (procedure)
•  ≡   Lung implantation (procedure)
•  ≡   Lymphatic system implantation (procedure)
•  ≡   Mediastinum implantation (procedure)
•  ≡   Mouth implantation (procedure)
•  ≡   Musculoskeletal system implantation (procedure)
•  ≡   Neck artery implantation (procedure)
•  ≡   Neck implantation (procedure)
•       Obstetric implantation (procedure)
•  ≡   Ovary implantation (procedure)
•  ≡   Pancreas implantation (procedure)
•  ≡   Penis implantation (procedure)
•  ≡   Pericardium implantation (procedure)
•  ≡   Pleura implantation (procedure)
•  ≡   Posterior segment of eye implantation (procedure)
•  ≡   Prostate implantation (procedure)
•  ≡   Rectum implantation (procedure)
•  ≡   Salivary gland implantation (procedure)
•  ≡   Scrotum implantation (procedure)
•  ≡   Seminal vesicle implantation (procedure)
•  ≡   Shoulder implantation (procedure)
•  ≡   Small intestine implantation (procedure)
•  ≡   Spinal cord implantation (procedure)
•  ≡   Spleen implantation (procedure)
•  ≡   Staple implantation procedure (procedure)
•  ≡   Stomach implantation (procedure)
•  ≡   Testis implantation (procedure)
•  ≡   Thigh implantation (procedure)
•  ≡   Thoracic artery implantation (procedure)
•  ≡   Thorax implantation (procedure)
•  ≡   Thymus implantation (procedure)
•  ≡   Thyroid gland implantation (procedure)
•  ≡   Trunk implantation (procedure)
•  ≡   Ureter implantation (procedure)
•  ≡   Urethra implantation (procedure)
•  ≡   Uterus implantation (procedure)
•  ≡   Vagina implantation (procedure)
•  ≡   Vas deferens implantation (procedure)
•  ≡   Vein implantation (procedure)
•  ≡   Vulva implantation (procedure)